IRRITANT CONTACT DERMATITIS

DEFINITION
Irritant contact dermatitis (ICD) is a cutaneous response to contact with an external chemical, physical, or biologic agent where endogenous factors such as skin barrier function and pre-existing dermatitis also play a role. Clasically, the criterias are: Acute Erythema Vesiculation Pruritus Chronic Dryness Scaling Fissuring

EPIDEMIOLOGY
Contact dermatitis constitutes 90 - 95 %o f all occupational skin diseases, and ICD constitutes about 80 percent of occupational contact dermatitis. No previous exposure to the irritant is necessary ICD caused by personal-care products and cosmetics is also common

ETIOLOGY
1. 2. 3. 4. Removal of surface lipids and water-holding substances Damage to cell membranes Epidermal keratin denaturation Direct cytotoxic effects

Chemical stimuli stimulates release of proinflammatory mediators, particularly cytokines, from nonirnrnune cutaneous cells (keratinocytes). Disruption of the skin barrier leads to release of cytokines such as interleukin 1 (IL-1), IL-1, and tumor necrosis factor- (TNF-). TNF- is one of the key cytokines in irritant dermatitis, leading to the increased expression of major histocompatibility complex class II and intracellular adhesion molecule 1 on keratinocytes.

INFLUENCING FACTOR
ICD is a multifactorial disease where both exogenous (irritant and environmental) and endogenous (host) factors play a role. 1. Exogenous Factors Type of irritant (pH, chemical activity) Crossover phenomenon may happen when more than one irritants are applied. It can give synergistic or antagonistic effect. Cutaneous penetration of irritant

Body temperature & ambient humidity It decrease the water content of the stratum corneum, making it more permeable to irritants. Mechanical factors (pressure, friction, abrasion) Environment (temperature, humidity) Other exposure factors: duration, prior or simultaneous exposures, direct versus airborne

2. Endogenous Factors Genetic factor It determine the variability in responsiveness to irritants.16 Additionally, a genetic predisposition to irritant susceptibility may be specific for each irritant. Gender Rather than a gender-related skin susceptibility, women have more extensive exposure to irritants and wet work and are more likely to seek treatment than men. No gender difference for ICD has been established experimentally. Age Children younger than 8 years of age are more susceptible to percutaneous absorption of chemicals and irritant reactions. Visible skin irritation (erythema) is decreased in older persons while invisible skin irritation (barrier damage) might be increased in the elderly. Skin site There are significant site differences in barrier function, making the skin of the face, neck, scrotum, and dorsal hands more susceptible to ICD. The palms and soles are comparatively more resistant. Atopy It is a hereditary tendency to be hypersensitive to certain allergens. A history of atopic dermatitis seems to be linked to an increased susceptibility to irritant dermatitis because of a lower threshold for skin irritation, impaired skin barrier function, and slower healing process.

CLINICAL FINDING BASED ON CLINICAL TYPE OF ICD

ICD has a spectrum of clinical features, which can be divided into several different categories, depending on the irritant and its exposure pattern. 1. Irritant reaction Is often seen in individuals who are exposed to wet work. An irritant reaction can resolve or progress to cumulative irritant dermatitis. Scaling Low-grade erythema Vesicles Erosions and is usually localized on the dorsum of the hands and fingers. 2. Acute ICD Acute ICD usually results from a single skin exposure to a strong irritant or caustic chemical, such as alkalis and acids, or as a result of a series of brief chemical or physical contacts.Irritant reaction quickly peaks and then immediately begins to heal upon removal of the irritant. Complete healing may take 4 weeks, with a good prognosis. Burning, itching, or stinging Erythema Edema

Vesiculation Exudation Bullae formation Tissue necrosis in more severe cases.

3. Delayed acute irritancy The delayed irritant reaction is acute but without visible signs of inflammation appearing until 8 to 24 hours or more after exposure. Otherwise, the clinical appearance and course are similar to those of an acute ICD. 4. Chronic cumulative ICD / Traumiterative ICD It develops as a result of repeated insults to the skin, where the chemicals involved are often multiple and weak and would not in themselves be strong enough to cause irritant dermatitis. The most common marginal irritants include soap, detergents, surfactants, organic solvents, and oils,2 which may also act as perpetuating factors once the dermatitis has become established. Cosmetic cumulative ICD is often in eyelid. The symptoms do not immediately follow exposure to the irritant, appearing after days, months, or years of exposure. Symptomp : Stinging, smarting, burning, and itching; pain as fissures develop. Skin finding : Dryness chapping erythema hyperkeratosis and scaling fissures and crusting Ill-defined borders, lichenification. In irritant reaction ICD also vesicles, pustules, and erosions. Distribution : In cumulative ICD usually starting at finger webspaces, spreading to sides and dorsal surface of hands and then to palms. In housewives often starting on fingertips (pulpitis). 5. Subjective (symptomatic, sensory) irritancy Subjective irritancy usually occurs on the face, head, and neck. Cosmetics, sunscreens, and woolen garments are commonly implicated. Patients complain of itching, tingling, stinging, burning, or smarting sensation within minutes of contact with an irritant, but without visible cutaneous changes. 6. Nonerythematous (suberythematous) irritation This is a state in which the irritation is not visually apparent, but is histologically visible. Sub-erythematous irritation has been linked with the use of consumer products containing significant amounts of surfactant.Common symptoms include burning, itching, or stinging. 7. Frictional dermatitis Mechanical irritation can result from repeated microtrauma and friction. Nipple dermatitis in patients with ill-fitting bras, and dermatitis from prosthetic limbs, mechanical injury from thorns and spines in plants. This type of contact irritation usually leads to dry, hyperkeratotic abraded skin, making it more vulnerable to the effects of irritants. 8. Traumatic reactions Traumatic reactions can develop after acute skin trauma as burns or lacerations and most commonly occurs on the hands and persists for about 6 weeks or longer. The healing process in this type of dermatitis is prolonged, and erythema, scaling, papules, or vesicles can appear.

9. Pustular or acneiform reactions Pustular or acneiform reactions are usually seen after occupational exposures to oils, tars, heavy metals, and halogens but also after the use of some cosmetics. The pustular lesions are sterile and transient and may develop several days after exposure. This type of dermatitis is seen especially among atopic and seborrheic patients. 10. Exsiccation eczematid Exsiccation eczematid usually occurs in elderly patients who frequently shower without reapplying moisturizers to their skin. Intense itching, dry skin, and ichthyosiform scaling are clinical features that characterize this irritant reaction.

COMMON IRRITANT
Animal products Cosmetics Skin cleansers cause irritation depending on the chemistry of their constituents. They remove surface lipid film, denature proteins, and damage the cell membrane. Degreasing agents Detergents Soaps, detergents, and waterless cleansers are the most common irritants. Dusts/friction Foods Foods, such as citrus peels, garlic, flour, and spices, can act as irritants. Pineapple juice contains bromelain, an irritating proteolytic enzyme. Low humidity Metal working fluids Tear gases Topical medicaments Solvents Water/wet work

John P M Sinaga 130110120004